|Head of Department||Pn. Noor Zahidah binti Ahmad Fadzil|
Medical Records Department is responsible for keeping patient's medical records safely at all times. t's located at Wisma Rekod opposite to Maternity Hospital. It plays an important role in health care institutions as being a referral centre for patient's treatment and care. Success or failure of a health care institution somewhat or rather depends on how well the medical records are managed. More than that, Medical Record Department also handles application for medical report and information as well as documentation.
1. Medical Records Unit at Wisma Rekod:
1.1 Main Medical Records Unit (K2)
1.2 Obstetric & Gynaecology Medical Records Unit (K3)
1.3 Neuroscience Medical Records Unit (K6)
1.4 Arced Medical Records Unit (K4)
2. Medical Records Unit at Clinical Department itself:
2.1 Surgery Medical Records Unit
2.2 Pediatric Medical Records Unit
2.3 Radiotherapy Medical Records Unit
2.4 Urology & Nephrology Medical Records Unit
2.5 Orthopedic Medical Records Unit
3. Medical Records Department act as advisor in management of medical records for the following Departments:
3.3 Medical Respiratory
3.4 Nuclear Medicine
3.8 Blood Bank
Medical Records Department shall be an effective information centre, efficient and be able to provide excellent and to provide an excellent services in medical profession and to be a model to all hospitals in Malaysia.
1) To build complete, effective, up-to-date and efficient Medical Records Management.
2) To become a centre in providing accurate, fast, efficient and reliable information.
3) To provide quality service in processing medical reports and medical board applications.
4) To build an integrity/unity spirit.
1) Medical Records Department operating at office hours.
2) Medical Records Department is responsible for keeping medical record in a safe place at all time.
3) Medical Records are prohibited area. No outsider are allowed unless with the authorized permission from the Director/ Head of Department.
4) Medical Records can not be taken out from the hospital without getting subpoena from the court.
5) Patient information can not be lead to third party without permission from the patient or legal heir.
6) All information for education and studies have to get permission from the Director of HKL.
7) Staffs that work with medical record have to sign 'Confidential Act'.
8) Patient's medical records which have been discharged must be sent to the Medical Records Department/ Record Office within 72 hours from the date of discharge.
9) Any information about statistic can not be issued to the public without permission from the director of HKL.
10) Smoking, eating or drinking are prohibited in the medical record area.
11) Every medical report application must be through Medical Records Department.
Medical Records Department provides the following services :-
(A) DURING OFFICE HOURS
1. Medical Records Management
1.1 Receiving of medical records inclusive all death cases
1.2 Patient Master Index
1.3 Binding of Medical Records
** Patient Medical Record will be arranged according to the List of Record Fill In Arrangement.
1.4 Colour Code
After Patient Medical Record are bind and insert into their folder it will be colour coding according to the last two
numbers based on their IC Number.
1.5 Keeping of medical records
1.6 Borrowing of medical records
- Process of borrowing patient's medical record or x-ray films need to uses tracer.
1.7 Culling and Disposal of medical records
- All patient medical record will be keep during certain period of time based on the Jadual Pelupusan Rekod Perubatan,
Kementerian Kesihatan Malaysia that issued by National Arced Malaysia. Period of keeping are differ for one discipline
|PERIOD OF KEEPING RECORD|
|7 YEARS||25 YEARS|
** All the medical record will be registered in the SPRP before handing to the Disposal Factory.
2. Medico Legal
2.1 Management of Medical Report
2.2 Management of Medical Board
2.3 Management of Subpoena
2.4 Management of Writ of Summons
3. Information and Documentation
3.1 Health Management of Information System
- Compilation of inpatient, outpatient, supportive services and adhoc statistics.
3.2 Perinatal Death
3.3 Notification of Infectious Diseases
3.4 Notification of Poisoning
3.5 Clinical Classification
3.6 Resource Centre of Research, Education and Investigation
3.7 Annual Report
4. National Indicator Approach
4.1 Delay in preparation of Medical Report.
4.2 Timeliness of dispatching of medical records of discharged patient to Medical Records Department/Specialist Out
(B) AFTER OFFICE HOURS
Tracing Patient Medical Record After Office Hour (ON-CALL)
Tracing patient medical record after office hour (ON-CALL) has to be done as a requirement for Hospital Kuala Lumpur in a way to achieve the Accreditation and ISO. Therefor, management of medical record has developed Tracing Patient Medical Record Team after office hour that known as On-Call team among the Medical Record Department Staff. This On-Call Team has start the operation since July 15, 2005 and operated at the Record Unit(K1).
On-Call team are based on the 2 rotation as follow:-
|Monday - Friday||5.30pm - 11.30pm|
7.30am - 3.30pm
3.30pm - 11.30pm
CONTINUING MEDICAL EDUCATION (CME)
Medical Record Department also organise Continuing Medical Education (CME) every Wednesday at 2.30 pm. All the topic presented will be involve things to maximize the quality of service in Medical Record Department. This CME will be attend by all the officers and a few of staff in the Medical Record Department without disturbing the working process in their unit.